Dysphagia after open heart surgery

Esophageal ulceration complicating doxycycline therapy

AIM: To report present state of iatrogenic drug-induced esophageal injury (DIEI) induced by medications in a private clinic.

METHODS: Iatrogenic drug-induced esophageal injury (DIEI) induced by medications has been more frequently reported. In a private clinic we encountered 36 cases of esophageal ulcerations complicating doxycycline therapy in a mainly younger Saudi population (median age 29 years).

RESULTS: The most frequent presenting symptoms were odynophagia, retrosternal burning pain and dysphagia (94%, 75% and 56%, respectively). The diagnosis was according to medical history and confirmed by endoscopy in all patients. Beside withdrawal of doxycycline, when feasible, all patients were treated with a proton-pump inhibitor (PPI) and a prokinetic. Thirty patients who reported to the clinic after treatment were improved within 1-7 (median 1.7) days.

CONCLUSION: Esophageal ulceration has to be suspected in younger patients with odynophagia, retrosternal burning pain and/or dysphagia during the treatment with doxycycline.

Drug-induced dysphagia

Dysphagia describes the disability or problems in swallowing a wet or dry bolus properly and is normally associated with an impaired transport of the bolus. Dysphagia can be accompanied by a pain sensation in the chest mostly caused by impaction of the food bolus in the esophagus. Odynophagia describes only the status of painful swallowing without an impairment of the swallow and transport function. Drug-induced dysphagia can be caused in two different ways. First as a normal drug side effect of the pharmacological action of the drug or as a complication of the therapeutic action of the drug. The normal drug side effect is most likely in drugs that affect smooth or striated muscle function or the sensitivity of the mucosa. The drug effect on smooth muscle function that causes dysphagia can be inhibitory or excitatory. Dysphagia is a common clinical symptom in patients with reduced perception of the pharyngeal mucosa which leads to an subjective impairment of swallowing. Dysphagia caused by a complication of the therapeutic action of a drug includes viral or fungal esophagitis in patients treated with immunosuppressive drugs or cancer therapeutic agents, or antibiotics and immunological reactions to certain drugs such as erythema exsudativa multiforme or Stevens-Johnson syndrome. Second, drug-induced dysphagia can be due to medication-induced esophageal injury (MIEI). In most cases this mucosal injury appears to be the direct result of prolonged contact of a potentially caustic drug with the esophageal mucosa. This form of medication-induced esophagitis is most likely to be found in elderly patients and patients with esophageal motility disorders.(ABSTRACT TRUNCATED AT 250 WORDS)

Pill-induced esophageal strictures: clinical features and risk factors for development

Clinical data from five subjects with pill-induced esophageal strictures and from the English-language literature on pill-induced esophageal damage were reviewed to determine risk factors for stricture development and to characterize this complication. Including our five cases, 195 patients with pill-induced damage and 39 patients with pill-induced strictures have been reported to date. Seventy-eight percent of the strictures were located in the proximal or mid-esophagus. Potassium chloride or quinidine preparations were incriminated in 60% of cases and were more likely to produce stricture than other medications commonly associated with esophageal damage (e.g., tetracycline). Older age, male gender, left atrial enlargement, ingestion of sustained-release formulations, and prior esophageal structural abnormality were all more commonly present in the subset with strictures (p less than 0.05 for each), even after appropriately controlling for medication. A logistic regression analysis revealed that older age and ingestion of sustained-release formulations were the most significant independent factors associated with stricture development (p less than 0.0001 for each). These findings indicate that stricture formation from pill-induced esophageal damage is dependent upon host-related factors as well as the caustic nature of the pill.

Induction of esophageal injuries by doxycycline and other pills. A frequent but preventable occurrence

Many specialists and general physicians remain unaware of the potential for and pathogenesis of drug-induced esophageal ulcerations. To promote a greater awareness of the importance of this problem, we have reviewed the literature, particularly in regard to the mechanisms of action and the clinical and therapeutic implications of these chemical injuries to the esophagus. There can be no doubt that the frequency of occurrence of drug-induced esophageal ulceration far exceeds that reflected in the reported cases appearing in the medical literature. Nor can we deny that much of the responsibility for this situation lies in the failure of the prescribing physician to educate his patients (and himself!) in the art of taking potentially harmful pills and capsules, particularly tetracycline, doxycycline, potassium chloride, and quinidine preparations. Although most such drug injuries are self-limited events, there have been a number of fatalities reported and at the very least they involve acute discomfort.

Medication-induced oesophageal injury. Survey of the literature

This is a review of the 127 cases of drug-induced oesophagitis reported in the English language literature since 1970. The most common symptoms reported were retrosternal pain, odynophagia, and dysphagia. Most cases were self-limited and symptoms resolved in 7 to 10 days with symptomatic therapy. Occasionally, severe odynophagia or dysphagia necessitated hospitalisation. Emepronium bromide, tetracycline and its derivatives, potassium chloride, and quinidine account for 89% of the reported cases of medication-induced oesophageal injury. 14 other medications have been reported to injure the oesophagus. Serious sequelae, including death, have been linked to potassium-induced oesophageal injury. With other medications, however, serious complications were rare. The diagnostic study of choice is endoscopy; an air-contrast barium swallow may also detect the often subtle mucosal abnormalities produced by medication injury. However, the diagnosis does not require confirmation by radiographical or endoscopic means in all cases, and the history alone may be sufficient to make the diagnosis in uncomplicated cases. Medication-induced oesophageal injury is preventable if pills are taken with an adequate amount of fluid and if the practice of taking medications immediately before bedtime is avoided.